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Female Perineum Important

Doctors Notes
Notes/Extra explanation
Please view our Editing File before studying this lecture to check for any changes.
Objectives
At the end of the lecture, the student should be able to describe the:
✓ Boundaries of the perineum.
✓ Division of perineum into two triangles.
✓ Boundaries & Contents of anal & urogenital triangles.
✓ Lower part of Anal canal.
✓ Boundaries & contents of Ischiorectal fossa.
✓ Innervation, Blood supply and lymphatic drainage of perineum.

Lecture
Outline
Introduction:
• The trunk is divided into 4 main cavities: thoracic, abdominal, pelvic, and perineal. (see image 1)
• The pelvis has an inlet and an outlet. (see image 2) The lowest part of the pelvic outlet is the perineum.
• The perineum is separated from the pelvic cavity superiorly by the pelvic floor.
• The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus muscle, and
associated connective tissue. (see image 3) We will talk about them more in the next lecture.

Image (1) Image (2) Image (3)

Note: this image is seen from ABOVE
Perineum (In this lecture the boundaries and relations are important)

o Perineum is the region of the body below the pelvic diaphragm

(The outlet of the pelvis)
o It is a diamond shaped area between the thighs.

Boundaries: (these are the external or surface boundaries)

Anteriorly Laterally Posteriorly

Medial surfaces of Intergluteal folds

Mons pubis
the thighs or cleft

Contents:
1. Lower ends of urethra, vagina & anal canal
2. External genitalia
Extra
3. Perineal body & Anococcygeal body
(we will now talk about these in the next slides)
Perineum Extra explanation:
Perineal body The perineal body is an irregular
fibromuscular mass. It is located at
the junction of the urogenital and
o Perineal body is an irregular fibromuscular mass of variable size and consistency, located at anal triangles – the central point of
midpoint of the line between the ischial tuberosities. the perineum. This structure contains
o Lies in the subcutaneous tissue, posterior to vaginal vestibule and anterior to the anal canal skeletal muscle, smooth muscle and
& anus collagenous and elastic fibres.
o Forms the central point of the perineum & blends anteriorly with the perineal membrane Anatomically, the perineal body lies
just deep to the skin. It acts as a point
of attachment for muscle fibres from
Function: the pelvic floor and the perineum
1. Gives attachment to perineal muscles itself
2. Plays an important role in visceral support especially in female

Perineal
membrane

Extra
These pictures are extra.
Perineum
Anococcygeal Body
o The anococcygeal body is a complex musculotendinous structure (more tendinous).
o Situated between the anterior aspect of the coccyx and the posterior wall of the anorectal canal
o Receives insertion of fibers of levator ani muscle (gives attachment of levator ani muscles).

: ‫يعني بالترتيب يكون‬

Vaginal vestibule
Perineal body
Anal canal
Anococcygeal body
Coccyx

Extra
Extra
Perineum
Divisions
Boundaries:
o Its bony boundaries are:
Anteriorly Laterally Posteriorly
Ischiopubic rami,
Symphysis pubis ischial tuberosities & Coccyx
sacrotuberous ligaments*

* ligament between sacrum and ischial tuberosity

Note the perineum has bony
boundaries and surface or ** this is the same line that passes through the perineal body
external boundaries:

Extra
Division:
o By an imaginary line** passing through two ischial tuberosities,
it is divided into:
I. Urogenital triangle anteriorly.
II. Anal triangle posteriorly.
In the next slides we will talk about the urogenital triangle in detail.
Extra Sacrum
 Extra
I. Urogenital Triangle

Boundaries:
Anteriorly Laterally Posteriorly
Transverse line
Ischiopubic rami &
Symphysis pubis passing through the 2
ischial tuberosities
ischial tuberosities

Contents:
1. Lower part of urethra & vagina.
2. External genitalia (vulva).
3. Urogenital diaphragm
The urogenital triangle : is associated with the structures of the urogenital
system – the external genitalia (genital part) and urethra (urinary part).
I. Urogenital Triangle
Female External Genitalia (Vulva) 04:24

The external genital organs of the female are collectively known as the vulva (also
called the pudendum). The vulva is comprised of many different structures:

1. Mons pubis: a collection of fat overlying the pubes

2. Labia majora (labia means lips or flaps).
3. Labia minora.
4. Clitoris (the two labia minora meet at a point anteriorly and make the clitoris).
5. Vestibule of vagina: The interval or area between the
two labia minora and has 2 openings:
6. Vagina & urethra open into the vestibule through
urethral orifice anteriorly and vaginal orifice posteriorly.

Extra
 Extra Explanation
There are many layers in the urogenital triangle
The first component is the urogenital diaphragm
which is composed of:
1. Superior layer of fascia of urogenital diaphragm Deep pouch
2. Deep transvers muscle + sphincter urethrae Superior layer of fascia of urogenital diaphragm
3. Inferior layer of fascia of urogenital diaphragm: Muscles (deep transverse & sphincter diaphragm)
this layer is also called perineal membrane. perineal membrane

The urogenital triangle extends downwards until the

skin. Below the skin we have the perineal fascia
which is divided into: Superficial pouch
1. Superficial perineal fascia: further divided into
deep membranous layer and
superficial fatty layer .
2. Deep perineal fascia Superficial fascia: deep membranous layer
NOTE: Remember that the superficial layer is the Superficial fascia: superficial fatty layer
one closer to the skin. Skin

Next we have the pouches which are above and

below the perineal membrane:
The deep pouch is basically the same as the
urogenital diaphragm (above perineal membrane).
The superficial pouch extends below the perineal
membrane to the deep membranous layer.
 I. Urogenital Triangle
Urogenital Diaphragm
• A triangular musculofascial diaphragm located in the
anterior part of the perineum (in the urogenital
triangle).
Extra
• Fills in the gap between the pubic arch.

• Composed of: musculo-fascial so it has muscles and fascia

(1) Sphincter urethrae and

muscle

(2) the deep transverse perineal muscles enclosed within

(3) the superior and (4) inferior layers of fascia of the

fascia

urogenital diaphragm (The inferior layer of the fascia

is formed by the perineal membrane) Extra
The fascia cover the muscle from above and below

Note: we have 2 fascia: perineal fascia (superficial and deep) and fascia of urogenital diaphragm (superior and inferior)
 I. Urogenital Triangle
Perineal Fascia

Perineal Fascia
Fascia of Urogenital Triangle (Perineal Fascia) is continuous anteriorly with
the fascia of abdomen and consists of 2 layers: superficial and deep layers

Superficial perineal fascia Deep perineal fascia

Consists of: invests the muscles in the
superficial perineal pouch
1. Superficial fatty layer (Camper’s fascia ) (the muscles will be mentioned
makes up the substance of mons pubis & labia later)
majora and extends into the anal region.
2. Deep membranous layer (Colle’s fascia ):
• Does not extend to anal region.
• Becomes fused with the posterior margin
of the perineal membrane
I. Urogenital Triangle
Perineal Pouches
Structurally, the urogenital triangle is complex, with a number of fascial layers and pouches. Unlike the anal triangle, the urogenital
triangle has an additional layer of strong deep fascia; the perineal membrane. This membrane has pouches on its superior and inferior
surfaces: the superficial and deep pouches.
Perineal Pouches
Superficial Perineal Pouch
o It is the potential space between the deep
membranous layer of superficial fascia and
the perineal membrane (inferior fascia of urogenital diaphragm).

o Boundaries:
Superiorly Laterally Inferiorly
Membranous
Perineal layer of
Ischiopubic rami
membrane superficial fascia
(colles fascia)
Perineal Pouches The contents are important.
Contents of Superficial Perineal Pouch (2)
(1)
(3-a)
1. Bulbs of vestibule: on each side of vaginal orifice. (3-b)

2. Crura of clitoris (crura: plural of “crus”) (4)

a) Ischiocavernosus muscle: (3-c)

covers crus of clitoris on each side.

3. Superficial perineal muscles: b) Bulbospongiosus muscle:

(see slide 6 for a picture of the muscles) surrounds orifice of vagina and covers
vestibular bulb.
c) Superficial transverse perineal
muscles

4. Greater vestibular glands: on each side of vaginal orifice.

5. Perineal branch of pudendal nerve: supplying muscles & skin.

Perineal Pouches
Deep Perineal Pouch
o It is a completely closed space deep to the
perineal membrane.
o It is the same as the urogenital diaphragm.

o Boundaries:
Superiorly Laterally Inferiorly
Inferior fascia of
Superior fascia of Inferior portion the urogenital
the urogenital of obturator diaphragm
diaphragm internus fascia (perineal
membrane)
Perineal Pouches
Contents of Deep Perineal Pouch (1)

(1)
1. Part of urethra
(4) (2)

2. Part of vagina

3. Sphincter urethrae and Sphincter vaginae muscles;

which is pierced by urethra & vagina.

4. Deep transverse perineal muscles

5. Internal pudendal vessels

6. Dorsal nerve of clitoris

Vagina
o The vagina is a muscular canal that leads from the uterus to
the external orifice of the genital canal
o It measures about 3 in. (8 cm) long.
o It serves as the excretory duct for the menstrual flow & forms
part of the birth canal.
o The vaginal orifice in a virgin possesses a thin mucosal fold,
called the hymen (‫)غشاء العذرية‬, which is normally perforated at its
center to allow the menstrual blood to flow out.

Arteries:
1. Vaginal artery, a branch of the internal iliac artery
2. Vaginal branch of the uterine artery

Veins:
1. drain into the internal iliac veins.

‫بعد عدة‬
‫والدات‬
II. Anal Triangle

Boundaries:
Anteriorly Laterally Posteriorly
Transverse line
ischial tuberosity &
passing through the Coccyx
sacrotuberous ligament.
2 ischial tuberosities

Contents:
1. Lower part of Anal canal
2. Ano-coccygeal body
3. Ischiorectal fossa on each side (will be discussed later)
II. Anal Triangle
Anal Canal
o It is about 1.5 in. long, descending from the rectal ampulla
to the anus.

Relations (In female):

Anteriorly Posteriorly Laterally
Perineal body,
Anococcygeal Ischiorectal
urogenital diaphragm,
body fossae
lower part of vagina
Extra
Division: Divided by pectinate line into:
1. Upper half: derived from hindgut* (endoderm)
2. Lower half: derived from the proctodeum (ectoderm)
The two parts have different blood supply, nerve supply and
lymphatic drainage.

*remember from GIT block: the artery of the hindgut is the inferior mesenteric artery
 This slide is important.
Anal canal Arterial supply Venous drainage Lymphatic drainage Nerves
Superior rectal artery Superior rectal vein Para-rectal nodes
(sensitive to stretch)
Upper half Visceral^ sensory & motor
(continuation of the drained into the inferior drained into
(endoderm) (Inferior Hypogastric Plexus)
inferior mesenteric mesenteric vein inferior mesenteric
(sympathetic & parasympathetic).
artery) (portal circulation). lymph nodes
Inferior rectal vein
(sensitive to pain)
Inferior rectal artery drained into the internal Somatic^ motor & sensory nerves
Lower half pudendal vein Superficial inguinal
(Inferior rectal N. branch of pudendal N.)
(ectoderm) (branch of internal (Systemic circulation*) lymph nodes
supplies: external sphincter muscle of the
pudendal artery) site of portal-systemic anus and the skin of the anal region.
anastomosis**. The name of the nerves are only
mentioned on the girls slides.
*Clinical importance:
in children we give medication in the ^to review the difference
form of suppository (‫ )تحميله‬We insert it between visceral and
in the lower half of the anal canal but somatic look at this picture:
we shouldn’t push it in too deeply
because then it will go to the portal
instead of the systemic circulation.

**In cases of portal hypertension this

will lead to hemorrhoids (‫)بواسير‬
II. Anal Triangle
Ischiorectal Fossa
o A fascial lined wedge-shaped space on each side of the anal
canal.
Boundaries:
Base Medial Wall Lateral Wall

Skin of the Levator ani & Obturator internus,

perineum. anal canal. covered with fascia.

Contents:
1. Dense fat.
2. Pudendal nerve & internal pudendal vessels within the
pudendal canal.
3. Inferior rectal nerve & vessels crossing the fossa to reach
anal canal.
II. Anal Triangle
Pudendal Canal
o The pudendal canal is a fascial canal formed by obturator fascia, located on the lateral wall of the
ischiorectal fossa.
Contents:
Mnemonic:
1. Pudendal nerve. VAN
2. Internal pudendal vessels (artery and vein).

Vein
Artery
Nerve

Extra
 II. Anal Triangle
Pudendal Nerve Block Important!
o Pudendal nerve block is used in providing analgesia for the second stage of labour
(‫ )الوالدة‬to provide anesthesia of the perineum in order to create or repair an
episiotomy (An episiotomy is a surgically planned incision on the perineum and the
posterior vaginal wall during second stage of labor to prevent perineal tear). Extra

o Method: can be done by transvaginally or through perineal approach.

Transvaginal method: Perineal method:

• The needle is passed through
the vaginal mucous
membrane toward the ischial
spine.
‫الفرق بين االثنين انه االول‬ • After the needle is passed
‫يكون من جوى الزم الدكتور‬
through the sacrospinous
. ‫يدخل من المهبل‬
‫بينما الطريقة الثانية تكون من‬
ligament, the anesthetic
‫برا الدكتور يحس العظم بعدين‬ solution is injected around
.‫يدخل اإلبرة على طول‬ the pudendal nerve
• The ischial tuberosity is palpated
subcutaneously through the
buttock. (needs experience)
• The needle is inserted on the medial
side of the ischial tuberosity to a
The cut is made in an
depth of about 1 in. (2.5 cm) from oblique line so we
the free surface of the tuberosity. don’t cut the perineal
• The anesthetic is injected around body
the pudendal nerve.
Perineum: region of the body below the pelvic diaphragm
•Contents: 1\Lower ends of urethra, vagina & anal canal- 2\ External genitalia- 3\ Perineal body & Anococcygeal body

Perineal body is an irregular fibromuscular mass, located at the midpoint of The anococcygeal body is a complex musculotendinous structure,
the line between the ischial tuberosities located between the anterior aspect of the coccyx and the posterior wall of
Function: the anorectal canal.
1-Gives attachment to perineal muscles. •Receives insertion of fibers of levator ani muscle
2-Plays an important role in visceral support especially in female.

Boundaries of Anteriorly Mons pubis \ Laterally Medial surfaces of the thighs \Posteriorly Intergluteal folds.
perineum:
Division of Urogenital triangle anteriorly: Anal triangle posteriorly:
perineum: • Boundaries: • Boundaries:
Anteriorly : Symphysis pubis. Anteriorly: Transverse line passing through the 2 ischial tuberosities.
Posteriorly : Transverse line passing through the 2 ischial tuberosities. Posteriorly : coccyx.
Laterally : Ischiopubic rami & ischial tuberosities. Laterally : ischial tuberosity & sacrotuberous ligament.
• Content: • Contents:
-Lower part of urethra & vagina. - Lower part of Anal canal.
-External genitalia (vulva). - Ano-coccygeal body.
- Ischiorectal fossa on each side.
Ischiorectal Boundaries: Contents:
-Base: Skin of the perineum. - Dense fat.
fossa:
-Medial wall: Levator ani & anal canal. - Pudendal nerve & internal pudendal vessels within the pudendal
-Lateral wall: Obturator internus, covered with fascia. canal.
- Inferior rectal nerve & vessels crossing the fossa to reach anal
canal.
 Urogenital Female External
Perineal Fascia Perineal Pouches Vagina Anal Canal Pudendal Canal:
Diaphragm Genitalia (Vulva)
• A triangular 1. Mons pubis. continuous anteriorly Superficial: -muscular canal that - 1.5 in. long, -A fascial canal
musculofascial 2. Labia majora. with the fascia of It is the space leads from the uterus descending from the formed by obturator
diaphragm located 3. Labia minora. abdomen. between the deep to the external rectal ampulla to the fascia, located on the
in in the urogenital 4. Clitoris. consists of: membranous layer orifice of the genital anus. lateral wall of the
triangle. 5. Vestibule of Superficial perineal of superficial fascia canal. Relations (In female): ischiorectal fossa
• Fills in the gap vagina. fascia: and the perineal - 3 in. (8 cm) long. Anteriorly: Contents:
between the pubic 6. urethral orifice & -Superficial fatty membrane. -It is the excretory Perineal body, 1-Pudendal nerve.
arch. vaginal orifice. layer (Camper’s duct for the urogenital
fascia). Deep: 2-Internal pudendal
menstrual flow & diaphragm, and
Composed of: - Deep membranous It is a completely lower part of vagina vessels.
forms part of the
1. Sphincter layer (Colle’s fascia ). closed space deep birth canal. Posteriorly:
urethrae Deep perineal fascia: to the perineal Anococcygeal body.
2. deep transverse invests the muscles membrane Arteries:
Laterally: Ischiorectal
perineal muscles. in the superficial -Vaginal artery, a fossae.
3. Superior layer of perineal pouch. branch of the Division:
urogenital fascia internal iliac artery Upper half: derived
4. Inferior layer of -Vaginal branch of from hindgut
urogenital fascia the uterine artery (endoderm)
(perineal Veins: Lower half: derived
membrane) internal iliac veins from the
proctodeum
(ectoderm)
*The two parts have
different blood
supply, nerve supply
and lymphatic
drainage.
 MCQs
Q1: All the following are contents of urogenital tringle except : Q5: Which of the following is a lateral boundary to deep perineal pouch?
A) Urethra B) Vagina A) Inferior portion of obturator internus fascia
C) Valva D) Anus B) Superior portion of obturator internus fascia
C) Ischiopubic rami
Q2:Which one of the following structures forms the center point of D) Superior fascia of the urogenital diaphragm
perineum?
A) Perineal body B) Ischial tuberosities
Q6: Vaginal branch originates from which of the following arteries?
C) Anococcygeal body D) Coccyx
A) Internal iliac artery B) Ovarian artery
C) Uterine artery D) Inferior mesenteric artery
Q3: Which one of the following structures lie anterior to Urogenital Triangle?
A) Ischiopubic rami B) Ischial tuberosities.
Q7: Which of the following vein drain the inferior rectal vein?
C) External genitalia D) Symphysis pubis
A) Uterine vein B) Internal pudendal vein
C) Superior mesenteric vein D) Inferior mesenteric vein
Q4: Which of the following is a content of superficial perineal pouch ?
A) Dosal nerve of clitoris B) Pudendal artery
Q8: The fascia canal of pudendal canal formed by which of the following?
C) Pudendal vein D) Perineal branch of pudendal nerve
A) Deep perineal fascia B) Superficial perineal fascia
C) Obturator fascia D) Superior fascia of urogenital
diaphragm

Answers: 1. D, 2. A, 3. D, 4. D, 5. A, 6. C, 7. B 8. C
 SAQ
Q1: Regarding the relation of the anal canal in female ?
1-Anteriorly: perineal body, urogenital diaphragm, lower
part of vagina
2- Posteriorly: anococcygeal body
3- Laterally: ischiorectal fossae
Q2: What’s the divisions of the anal canal and from
where it’s derived ?
- Upper half: Derived from hindgut (endoderm)
- Lower half: Derived from proctodeum (ectoderm)
Q3: What are the contents of the superficial pouch?
1. Bulbs of vestibule.
2. Crura of clitoris
3. Superficial perineal muscles:
a) Ischiocavernosus muscle.
b) Bulbospongiosus muscle.
c) Superficial transverse perineal muscles
4. Greater vestibular glands.
5. Perineal branch of pudendal nerve.
Q4: What are the bony boundaries of the perineum?
1-Anteriorly: Symphysis pubis
2- Posteriorly: Coccyx
3- Laterally: Ischiopubic rami, ischial tuberosities &
sacrotuberous ligaments
Q5: What are the contents of the urogenital triangle?
1. Lower part of urethra & vagina.
2. External genitalia (vulva).
Q6: What are the contents of the anal triangle?
1. Lower part of Anal canal
2. Ano-coccygeal body
3. Ischiorectal fossa on each side
Q6: What are the contents of the pudendal canal?
1. Pudendal nerve.
2. Internal pudendal vessels
Leaders: Members:
Nawaf AlKhudairy Alanoud Abuhaimed
Anwar Alajmi
Jawaher Abanumy
Ghaida Alsaeed
Lama Alfawzan
Lama AlTamimi
Rawan AlWadee
Safa Al-Osaimi
Shatha Alghaihb
Wejdan alzaid

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